Letter to the Editor
17
“Meglio e La Piccola Certezza Che la Gran Bugia” (The Little Truth is Better than the Big Lie) – Leonardo da Vinci Or: The Obligation to Say “Yes” and a Right to Say “No” 1 Medical Practice of Neurology, Psychiatry, Psychosomatic Medicine,
Analytic Psychology, Munich, Germany Thorac Cardiovasc Surg 2016;64:17–18.
I read the publication of Gansera et al, entitled “High-risk cardiac surgery in patients with intravenous (IV) drug abuse and/or active hepatitis C/HIV infection: an ethical discussion of 6 cases,”1 as well as its accompanying commentaries with great interest. As a psychiatrist, neurologist, and psychotherapist, I would like to congratulate the editor on this new forum, which allows the reader to participate actively in the discussion and conclusion section. One would like to see such an innovative platform implemented in other disciplines too; this “pioneering work” hopefully will give an impulse as a precursor for imitation in other renowned scientific journals. After nearly 30 years of clinical experience, also with drug addicts, as a psychiatrist or psychotherapist, I would like to add some rather subject-specific remarks, preferentially concerning the psychological point of view, but not in terms of how to decide from the surgical perspective, as this is not my area of expertise. Superficially, there is no doubt about the necessity and obligation to perform an operation on each emergent patient without hesitation when technical feasibility is given. In my opinion, there is consensus within the original article and the invited commentaries on this responsibility. As the title suggests, my remarks are divided into two parts.
Address for correspondence Hans-Christian Weiland, MD, Medical Practice of Neurology, Psychiatry, Psychosomatic Medicine, Analytic Psychology, Agnesstrasse 24, 80798 Munich, Germany (e-mail: [email protected]).
rational approach. The concept of compulsiveness is chosen instead as most operationally meaningful, both in this particular field and in psychopathology in general. As a criterion it serves to establish single mental acts rather than whole persons, as emotionally sick, and as such proves especially useful, fruitful, and elucidating. No look at the hidden dimension can fail to notice the connections between the main underlying problems in the individual and socio-cultural and philosophical antitheses, conflicts, and contradictions. The psychoanalyst is in a delicate position: he cannot advocate concrete ethical values but must remain, even in his clinical work, a scientist primarily beheld to the value system inherent in every scientific method. Yet, as it applies to this field (integration, freedom from compulsions, integrity and honesty, etc.) this value system has an ineluctable effect upon his material decisions.”
For “the obligation to say yes” in psychological care in addict patients, I would like to begin with the citation of some lines written by the famous psychoanalyst Leon Wurmser in his oeuvre, entitled The Hidden Dimension: Psychodynamics of Compulsive Drug Use2:
To the best of my knowledge, no one but Leon Wurmser ever found clearer words to describe the dilemma of drug addicts. In my own long-lasting experience during work with IV drug abusers, I had to find out that their behavior seems to be primarily impressed by an addicted pole, which steps aside and negates any autonomy upon decisions. Of course, we do respect addicts as much as all other equal human beings, with recognition and show the same feeling of self-worth and empathy to them as to all other patients. Nevertheless, in contrary to other dependencies, for example, alcoholism, the psychodynamic paradigm of chronic IV drug addicts does not seem to be affected by deeper insights, insofar as confrontation with reality is associated with a huge extent of disavowal and expulsion of the real problem in most of the patients. Leon Wurmser2 wrote:
“Differentiating non-intensive from heavy drug use shows that socio-legal definitions are woefully inadequate for a
“I was often hit by the provocative nature of their habits and attitudes, felt anger about being lied to and
“The Obligation to Say Yes”
published online January 5, 2016
© 2016 Georg Thieme Verlag KG Stuttgart · New York
DOI http://dx.doi.org/ 10.1055/s-0035-1570098. ISSN 0171-6425.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Hans-Christian Weiland1
Letter to the Editor manipulated or scorned about, flouting of all efforts to help them and of all the rules we live by. … The complexity of this problem, namely that psychological factors are so tightly interwoven with sociological, economic and legal factors which need introspection and empathy, must take a backseat when values of power, expediency, public success and cost efficiency are uppermost.” These thoughts echo my own experience. During many years of work, I tried to overcome the stereotypes of some of my colleagues about the “lack of motivation” in drug addicts. Although the level of manipulation and exhortation against therapists in these patients seems to be immense, instead of prejudice and the frequent neglect of recognizing psychological problems or emotional conflicts as a substantial background of drug abuse, the only way to help is to understand. Non ridere, non lugere, neque detestari, sed intelligere (Not to deride, not to grieve, not to detest, but to comprehend). – Spinoza For more than two decades, I followed this challenging concept until I decided, apart from exceptional cases, not to work with IV drug addicts anymore, predominantly due to the helplessness to help.
“The Right to Say No” Objective data: The number of drug-induced deaths (2013) in Germany revealed 1,002 with an increasing tendency (6% within the past 6 years). A total of 80% of these fatal casualties had German nationality, and death-causing drugs were opiates in 66%. The statistical report of the year 2013 on substance abuse treatment in Germany (DSHS), based on 822 outpatient and 200 inpatient centers, reports 334,258 and 47,354 cases of care, respectively.3 Given the large number of patients, the German drug treatment system is among the most extensive in Europe. Costs for rehabilitation of addiction patients were €495 million in 2013, corresponding to 15% of the total package for medical rehabilitation efforts. Unscheduled termination of therapy occurred predominantly in opiate abuse (outpatient: 47%; inpatient: 37%). These data, in particular concerning early breakup of therapy, somehow underpin my own experience with drug addicts. I have seen and treated patients with and without endocarditis and even in cases after redo valve replacement, thus in a life-threatening situation. A minority was willing to get clean. Moreover, not only the passivity of drug addicts, but also their behavior expressed in words like: “If you tell me such sad things I will leave and never come back” or “Give me my stuff, otherwise I will perform suicide” may describe their attitudes. Such desperate statements might conceivably be transferable to cardiac surgeons: “Perform surgery and make me healthy, that’s your job.” In this context, “scandalized cultural readings of addiction and infection,” as mentioned within Prof. Paul’s comment, are Thoracic and Cardiovascular Surgeon
Vol. 64
No. 1/2016
strong words and probably do the authors injustice, especially as they seem to come from a more theoretical background rather than from practical experience with addicts. Probably, “epistemologically well-founded” statistic risks are one thing, daily experience is another. The medical review of Gansera et al obviously was also part of the discourse between surgeons and nurses, whether one has the right to say no or not, a discourse with respect to ethical and live-practical aspects. How to argue with a nurse when her predecessor was hurt by a HIV-infected needle? One should have worked very close and in person with addicts before writing theoretical pieces of wisdom on the pin board. I cannot answer the question about how often redoes should be performed in addicts, but I can answer the question whether one has the right to say no or not, or whether it may be legitimate to delegate therapy to other experienced colleagues (self-evidently exclusive of emergencies). I myself refused, beyond exceptional cases, further psychological therapy in chronic IV drug abusers, and I will finally give a short draft of my reasons. Of course, the position of a psychological therapist/psychiatrist is limited, comparable to that of a cardiac surgeon. The psychological dynamics of chronic IV drug addicts are characterized by a mental “position of sacrifice,” which instruments therapists in terms of patient-own passiveness. A huge part of this collective does not come with an idea of a real will for therapy, but rather with different shapes of psychoses, anxiety disorders, personality disorders, which, without question, need treatment. These patients rarely expect psychological therapy or support, but solely want some pain treatment or drug substitution. They do not come back if one does not fulfill their desired perception. Thus, changing concepts of this clientele are rarely affected by any own attitude toward a therapeutic intention or a will to abstinence. The dynamics for a deliberate escape from the addiction spiral are mostly not given. Most of these patients refuse each consequent position for abstinence or against “self- destroying,” and they convert confrontation with the truth using arguments like absence of humanity or lack of empathy. After two decades of experience with drug addicts, I nowadays refer some of these patients to reputable colleagues, who have plenty of time to spend with them. I preferentially dedicate myself to patients who show at least some serious motivation to receive optimal treatment. Is this approach to say “no” reprehensible? I do not think so.
References 1 Gansera LS, Eszlari E, Deutsch O, Eichinger WB, Gansera B. High-
risk cardiac surgery in patients with intravenous drug abuse and/ or active hepatitis C or HIV infection: an ethical discussion of six cases. Thorac Cardiovasc Surg 2015 doi: 10.1055/s-0035-1549162 2 Wurmser L. The Hidden Dimension: Psychodynamics of Compulsive Drug Use. New York/London: Jason Aronson; 1977 3 Jahrbuch Sucht. Deutsche Hauptstelle für Suchtfragen E.V. Lengerich. Germany: Pabst Science Publishers; 2015
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
18
17
“Meglio e La Piccola Certezza Che la Gran Bugia” (The Little Truth is Better than the Big Lie) – Leonardo da Vinci Or: The Obligation to Say “Yes” and a Right to Say “No” 1 Medical Practice of Neurology, Psychiatry, Psychosomatic Medicine,
Analytic Psychology, Munich, Germany Thorac Cardiovasc Surg 2016;64:17–18.
I read the publication of Gansera et al, entitled “High-risk cardiac surgery in patients with intravenous (IV) drug abuse and/or active hepatitis C/HIV infection: an ethical discussion of 6 cases,”1 as well as its accompanying commentaries with great interest. As a psychiatrist, neurologist, and psychotherapist, I would like to congratulate the editor on this new forum, which allows the reader to participate actively in the discussion and conclusion section. One would like to see such an innovative platform implemented in other disciplines too; this “pioneering work” hopefully will give an impulse as a precursor for imitation in other renowned scientific journals. After nearly 30 years of clinical experience, also with drug addicts, as a psychiatrist or psychotherapist, I would like to add some rather subject-specific remarks, preferentially concerning the psychological point of view, but not in terms of how to decide from the surgical perspective, as this is not my area of expertise. Superficially, there is no doubt about the necessity and obligation to perform an operation on each emergent patient without hesitation when technical feasibility is given. In my opinion, there is consensus within the original article and the invited commentaries on this responsibility. As the title suggests, my remarks are divided into two parts.
Address for correspondence Hans-Christian Weiland, MD, Medical Practice of Neurology, Psychiatry, Psychosomatic Medicine, Analytic Psychology, Agnesstrasse 24, 80798 Munich, Germany (e-mail: [email protected]).
rational approach. The concept of compulsiveness is chosen instead as most operationally meaningful, both in this particular field and in psychopathology in general. As a criterion it serves to establish single mental acts rather than whole persons, as emotionally sick, and as such proves especially useful, fruitful, and elucidating. No look at the hidden dimension can fail to notice the connections between the main underlying problems in the individual and socio-cultural and philosophical antitheses, conflicts, and contradictions. The psychoanalyst is in a delicate position: he cannot advocate concrete ethical values but must remain, even in his clinical work, a scientist primarily beheld to the value system inherent in every scientific method. Yet, as it applies to this field (integration, freedom from compulsions, integrity and honesty, etc.) this value system has an ineluctable effect upon his material decisions.”
For “the obligation to say yes” in psychological care in addict patients, I would like to begin with the citation of some lines written by the famous psychoanalyst Leon Wurmser in his oeuvre, entitled The Hidden Dimension: Psychodynamics of Compulsive Drug Use2:
To the best of my knowledge, no one but Leon Wurmser ever found clearer words to describe the dilemma of drug addicts. In my own long-lasting experience during work with IV drug abusers, I had to find out that their behavior seems to be primarily impressed by an addicted pole, which steps aside and negates any autonomy upon decisions. Of course, we do respect addicts as much as all other equal human beings, with recognition and show the same feeling of self-worth and empathy to them as to all other patients. Nevertheless, in contrary to other dependencies, for example, alcoholism, the psychodynamic paradigm of chronic IV drug addicts does not seem to be affected by deeper insights, insofar as confrontation with reality is associated with a huge extent of disavowal and expulsion of the real problem in most of the patients. Leon Wurmser2 wrote:
“Differentiating non-intensive from heavy drug use shows that socio-legal definitions are woefully inadequate for a
“I was often hit by the provocative nature of their habits and attitudes, felt anger about being lied to and
“The Obligation to Say Yes”
published online January 5, 2016
© 2016 Georg Thieme Verlag KG Stuttgart · New York
DOI http://dx.doi.org/ 10.1055/s-0035-1570098. ISSN 0171-6425.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Hans-Christian Weiland1
Letter to the Editor manipulated or scorned about, flouting of all efforts to help them and of all the rules we live by. … The complexity of this problem, namely that psychological factors are so tightly interwoven with sociological, economic and legal factors which need introspection and empathy, must take a backseat when values of power, expediency, public success and cost efficiency are uppermost.” These thoughts echo my own experience. During many years of work, I tried to overcome the stereotypes of some of my colleagues about the “lack of motivation” in drug addicts. Although the level of manipulation and exhortation against therapists in these patients seems to be immense, instead of prejudice and the frequent neglect of recognizing psychological problems or emotional conflicts as a substantial background of drug abuse, the only way to help is to understand. Non ridere, non lugere, neque detestari, sed intelligere (Not to deride, not to grieve, not to detest, but to comprehend). – Spinoza For more than two decades, I followed this challenging concept until I decided, apart from exceptional cases, not to work with IV drug addicts anymore, predominantly due to the helplessness to help.
“The Right to Say No” Objective data: The number of drug-induced deaths (2013) in Germany revealed 1,002 with an increasing tendency (6% within the past 6 years). A total of 80% of these fatal casualties had German nationality, and death-causing drugs were opiates in 66%. The statistical report of the year 2013 on substance abuse treatment in Germany (DSHS), based on 822 outpatient and 200 inpatient centers, reports 334,258 and 47,354 cases of care, respectively.3 Given the large number of patients, the German drug treatment system is among the most extensive in Europe. Costs for rehabilitation of addiction patients were €495 million in 2013, corresponding to 15% of the total package for medical rehabilitation efforts. Unscheduled termination of therapy occurred predominantly in opiate abuse (outpatient: 47%; inpatient: 37%). These data, in particular concerning early breakup of therapy, somehow underpin my own experience with drug addicts. I have seen and treated patients with and without endocarditis and even in cases after redo valve replacement, thus in a life-threatening situation. A minority was willing to get clean. Moreover, not only the passivity of drug addicts, but also their behavior expressed in words like: “If you tell me such sad things I will leave and never come back” or “Give me my stuff, otherwise I will perform suicide” may describe their attitudes. Such desperate statements might conceivably be transferable to cardiac surgeons: “Perform surgery and make me healthy, that’s your job.” In this context, “scandalized cultural readings of addiction and infection,” as mentioned within Prof. Paul’s comment, are Thoracic and Cardiovascular Surgeon
Vol. 64
No. 1/2016
strong words and probably do the authors injustice, especially as they seem to come from a more theoretical background rather than from practical experience with addicts. Probably, “epistemologically well-founded” statistic risks are one thing, daily experience is another. The medical review of Gansera et al obviously was also part of the discourse between surgeons and nurses, whether one has the right to say no or not, a discourse with respect to ethical and live-practical aspects. How to argue with a nurse when her predecessor was hurt by a HIV-infected needle? One should have worked very close and in person with addicts before writing theoretical pieces of wisdom on the pin board. I cannot answer the question about how often redoes should be performed in addicts, but I can answer the question whether one has the right to say no or not, or whether it may be legitimate to delegate therapy to other experienced colleagues (self-evidently exclusive of emergencies). I myself refused, beyond exceptional cases, further psychological therapy in chronic IV drug abusers, and I will finally give a short draft of my reasons. Of course, the position of a psychological therapist/psychiatrist is limited, comparable to that of a cardiac surgeon. The psychological dynamics of chronic IV drug addicts are characterized by a mental “position of sacrifice,” which instruments therapists in terms of patient-own passiveness. A huge part of this collective does not come with an idea of a real will for therapy, but rather with different shapes of psychoses, anxiety disorders, personality disorders, which, without question, need treatment. These patients rarely expect psychological therapy or support, but solely want some pain treatment or drug substitution. They do not come back if one does not fulfill their desired perception. Thus, changing concepts of this clientele are rarely affected by any own attitude toward a therapeutic intention or a will to abstinence. The dynamics for a deliberate escape from the addiction spiral are mostly not given. Most of these patients refuse each consequent position for abstinence or against “self- destroying,” and they convert confrontation with the truth using arguments like absence of humanity or lack of empathy. After two decades of experience with drug addicts, I nowadays refer some of these patients to reputable colleagues, who have plenty of time to spend with them. I preferentially dedicate myself to patients who show at least some serious motivation to receive optimal treatment. Is this approach to say “no” reprehensible? I do not think so.
References 1 Gansera LS, Eszlari E, Deutsch O, Eichinger WB, Gansera B. High-
risk cardiac surgery in patients with intravenous drug abuse and/ or active hepatitis C or HIV infection: an ethical discussion of six cases. Thorac Cardiovasc Surg 2015 doi: 10.1055/s-0035-1549162 2 Wurmser L. The Hidden Dimension: Psychodynamics of Compulsive Drug Use. New York/London: Jason Aronson; 1977 3 Jahrbuch Sucht. Deutsche Hauptstelle für Suchtfragen E.V. Lengerich. Germany: Pabst Science Publishers; 2015
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
18
